US8241210B2 - Vessel retractor - Google Patents

Abstract

A surgical apparatus includes an elongate cannula having a lumen extending therein between proximal and distal ends, a retractor disposed to slide within the lumen to extend a distal end thereof beyond the distal end of the cannula, an angling device connected to the retractor near the distal end of the retractor and extending within the cannula toward the proximal end thereof for selectively deflecting the distal end of the retractor away from a central axis of the cannula in response to manual manipulation of the angling device from near the proximal end of the cannula, wherein the distal end of the retractor is configured to move, upon extension, an object away from the central axis of the cannula.

Description

RELATED APPLICATIONS

The present application is a continuation of application Ser. No. 10/807,368, filed on Mar. 22, 2004, which is a continuation of application Ser. No. 10/218,475, filed on Aug. 12, 2002, now issued as U.S. Pat. No. 6,752,756, which is a continuation of application Ser. No. 09/490,552, filed Jan. 25, 2000, and now issued as U.S. Pat. No. 6,432,044, which is a continuation of Ser. No. 09/227,393, filed Jan. 8, 1999, now abandoned, which is a continuation-in-part application of application Ser. No. 09/102,723 filed on Jun. 22, 1998, now issued as U.S. Pat. No. 5,895,353 and the subject matter hereof is related to the subject matter of application Ser. No. 08/593,533 entitled “Tissue Separation Cannula” filed on Jan. 24, 1996 by Albert K. Chin, now abandoned, which is a continuation-in-part application of application Ser. No. 08/502,494, entitled “Tissue Separation Cannula And Method,” filed on Jul. 13, 1995, now abandoned, which prior applications are assigned to the same assignee as the present application and are incorporated herein in their entireties by this reference thereto.

FIELD OF THE INVENTION

This invention relates to a cannula used for vessel retraction, and more particularly to a cannula and method for retracting a vessel during dissection and transection.

BACKGROUND OF THE INVENTION

One important component of a surgical cannula is the tip, disposed on the distal end of the cannula. A properly configured tip can provide important functionality to a cannula. For example, the functions of vessel dissection and transection are commonly performed by two separate instruments. The device described in the pending application Ser. No. 08/907,691, entitled “Tissue Separation Cannula with Dissection Probe and Method,” filed on Aug. 8, 1997, discloses a device for separating surrounding connective tissue from a vessel (dissection). The device described in the pending application Ser. No. 09/102,723, entitled Vessel Isolating Retractor Cannula and Method,” filed on Jun. 22, 1998, discloses a device for retracting the vessel, ligating side branches, and transecting the branches to allow removal of the vessel. It is desirable to use a single device for performing the above functions.

The construction of a cannula tip also affects the visual field provided to a surgeon through an endoscope. When an endoscope is situated in a lumen of the cannula, the surgeon looks through the endoscope and through the transparent tip to view the surgical site. It is desirable to have a tip which maximizes the visual field of the endoscope.

The cannula tip may also be used to dilate a tunnel or anatomical space through tissue planes. In pending application Ser. No. 09/133,136, entitled “TISSUE DISSECTOR APPARATUS AND METHOD,” filed Aug. 12, 1998, assigned to the same assignee as the present application, and which is hereby incorporated by reference, a cannula is constructed with a bulbous element near the tip of the cannula for performing tissue dilation as the cannula is advanced. Cannula tips for dilating tunnels through tissue require force in order to advance the cannula and dilate the tissue. It is desirable to have a tip which can perform tissue dilation or dissection using a minimal amount of force and causing minimal trauma.

SUMMARY OF THE INVENTION

In accordance with the present invention, a tissue retractor is positioned within a cannula with a dissection cradle end of the retractor positioned at the distal end of the cannula. The retractor includes a first portion that has an axis approximately parallel to a central axis of the cannula, and a second portion that has an axis which is at an angle with respect to the central axis of the cannula. The dissection cradle is located at the distal end of the second portion of the retractor. In another embodiment, the retractor includes two legs having substantially parallel axes that selectively protrude from the distal end of the cannula. The protruding legs support the dissection cradle formed in the shape of a loop that is positioned in a plane skewed relative to the axes of the legs, with a bottom of the loop directed away from the cannula. Thus, in operation, when the surgeon locates a vein and side branch of interest, the surgeon extends the retractor to cradle the vein in the dissection cradle. Once cradled, the retractor may be fully extended to urge the vein away from the axis of the cannula, causing the side branch to be isolated and exposed to a surgical tool. The surgical tool may then be extended from within the cannula to operate on the isolated and exposed side branch.

In another embodiment, the top of the loop of the dissection cradle is flat and thin, allowing atraumatic support of the vein, and minimizing contact between the retractor and the surgical tool. In yet a further embodiment, the retractor includes a single leg with the loop formed by the one leg of the retractor, and with a stopper coupled to the distal end of the retractor. In still another embodiment, the cannula comprises a sliding tube which encases the retractor, and in a first position is extended out to encase the second portion of the retractor, and in a second position is extended to encase only the first portion of the retractor. In response to the sliding tube being in the first position, the second and first portions of the retractor are both approximately parallel to the axis of the cannula. In response to the sliding tube being in the second position, the second portion of the retractor is skewed relative to the axis of the cannula.

In accordance with an alternate embodiment of the present invention, a removable, transparent tip is positioned at the distal end of the cannula to provide a single cannula for performing dissection and transection. When attached, the tip seals the distal end of the cannula in a fluid resistant manner. The tip is conical and ends in a sharp interior point and a slightly rounded exterior point which allows the surgeon to bluntly dissect tissue in the area of interest under endoscopic visualization. When tissue dissection is complete, the surgeon can remove the tip from the cannula, and the surgeon is now able to use the cannula to transect side branches and vessel ends. In order to maximize the visual field provided by the endoscope, the tip is configured to allow the apex of the tip to be aligned with the central axis of the endoscope. In one embodiment, a distal end of the tip is tilted in an oblique fashion to allow the apex of the tip to align with or near to the central axis of the endoscope. In an alternate embodiment, the conical end of the tip has unequal taper angles relative to a plane of transition between the cylindrical and conical portions of the tip, thus skewing the position of the apex of the tip into alignment with or near to the central axis of the endoscope.

In another embodiment, wing-like protrusions are provided about the cannula near the tip to dilate tissue surrounding the vessel of interest. In one embodiment, the wing-like protrusions are diametrically aligned in a planar configuration with tapered forward edges extending rearward from near the apex of the tip. The planar configuration of the wing-like dilating protrusions near the tip substantially reduces the resistive force encountered during advancement of the cannula through tissue. The wing-like protrusions are positioned on opposite sides of the tip to dissect tissue to form a cavity that may attain a round cross-section under insufflation, thus providing the same resultant tissue dilation as provided by a solid oval dilator, but with less force required to accomplish the tissue dilation. In an alternate embodiment, the leading edges of the wing-like protrusions are curved in a parabolic configuration away from the distal end of the cannula to provide the necessary dilation.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective view of a preferred embodiment ofcannula100 showingretractor112 in an extended position.

FIG. 2ais a cut-away side view ofretractor112 andcannula100.

FIG. 2bis a top view ofretractor112.

FIG. 3ais a perspective side view ofcannula100 with a sapphenous vein positioned within thecradle116.

FIG. 3bis a perspective side view of thedistal end122 ofcannula100 in an embodiment in which anendoscope126 and asurgical tool120 are present and partially extended.

FIG. 3cis a front view of thedistal end122 ofcannula100 in which thesurgical tool120 and theretractor116 are partially extended, and anendoscope126 is present.

FIG. 4ais a cut-away top view ofcannula100.

FIG. 4bis a cut-away side view ofcannula100.

FIG. 5ais a cut-away view of a sliding tube embodiment ofcannula100 in a first position.

FIG. 5bis a cut-away view of the sliding tube embodiment ofFIG. 5ain a second position.

FIG. 6ais a cut-away view of an embodiment ofcannula100 having anangling device140.

FIG. 6bis a cut-away side view of the apparatus illustrated inFIG. 6ain which theretractor112 is extended and theangling device140 is actuated.

FIG. 6cis a cut-away side view of the angling device embodiment in which theangling device140 is in a separate lumen from theretractor112.

FIG. 7ais a cut-away side view of atwistable retractor112 in a straight position.

FIG. 7bis a side view of theretractor112 ofFIG. 7a.

FIG. 7cis a cut-away side view oftwistable retractor112 in a crossed position.

FIG. 7dis a side view of theretractor112 ofFIG. 7c.

FIG. 8ais a cut-away side view of thehandle104.

FIG. 8bis a cut-away side view of an alternate embodiment ofhandle104.

FIG. 9ais a side view ofcradle116.

FIG. 9billustrates a first alternate embodiment ofcradle116.

FIG. 9cillustrates multiple views of a second alternate embodiment ofcradle116.

FIG. 9dillustrates multiple views of a third alternate embodiment ofcradle116.

FIG. 9eillustrates multiple views of a fourth alternate embodiment ofcradle116.

FIG. 9fillustrates multiple views of a fifth alternate embodiment ofcradle116.

FIG. 9gillustrates multiple views of an embodiment ofcradle116 having a spur.

FIG. 10aillustrates a top view of an embodiment of thecradle116 ofFIG. 9cwithout a “C” ring.

FIG. 10billustrates a side view of thecradle116 ofFIG. 10a.

FIG. 10cillustrates a top view of thecradle116 ofFIG. 9cwith the “C” ring attached.

FIG. 10dillustrates a side view of thecradle116 ofFIG. 10c.

FIG. 11aillustrates a cut-away side view of atip1100 in a cannula housing anendoscope126.

FIG. 11billustrates a side view of thetip1100 isolated fromcannula100.

FIG. 12aillustrates a side view of an offsettip1200 in accordance with the present invention.

FIG. 12billustrates a cut-away side view of the offsettip1200 in acannula100 housing anendoscope126.

FIG. 12cillustrates a cut-away side view of an alternate embodiment of offsettip1200.

FIG. 13 illustrates a cut-away side view of an alternate embodiment of the offset tip1300.

FIG. 14aillustrates a perspective side view of the offsettip1200 and mountingrod1404.

FIG. 14billustrates a perspective side view ofcannula100 for housing offsettip1200 and mountingrod1404.

FIG. 14cillustrates a perspective side view of offsettip housing1424 at the proximal end of thecannula100.

FIG. 14dillustrates a perspective side view ofcannula100 with offsettip1200 and offsettip housing1424.

FIG. 14eillustrates a perspective side view of an alternate embodiment of offsettip mount1424.

FIG. 14fillustrates a cut-away side view of the offset tip mounting1424 ofFIG. 14e.

FIG. 15aillustrates a side view of an alternate embodiment of offsettip1200.

FIG. 15billustrates a side view of acannula100 modified for use with the offsettip1200 ofFIG. 15a.

FIG. 16 is a flow chart illustrating a method of dissecting and transecting vessels according to the present invention.

FIG. 17aillustrates a top view of an embodiment of an offsettip dilator1700 according to the present invention.

FIG. 17billustrates a side view of the embodiment of offset tip dilator1716 ofFIG. 17a.

FIG. 17cillustrates a top view of an alternate embodiment of offsettip dilator1700.

FIG. 18 is a flow chart illustrating a method of dilating tissue in accordance with the present invention.

DETAILED DESCRIPTION OF THE INVENTION

FIG. 1 illustrates a perspective view of a preferred embodiment ofcannula100 showingretractor112 in an extended position.Cannula100 includes an outer housing102 of bioinert material such as polymed UD that may be approximately 12″ to 18″ in length. The proximal end of thecannula100 is disposed inhandle104 that includes abutton106 which is coupled toretractor112 for controlling the translational movement ofretractor112, as described in more detail below.

The distal end of the cannula houses aretractor112, and optionally anendoscope126 and asurgical tool120, described below.FIG. 2aillustrates theretractor112 in more detail. In one embodiment,retractor112 is formed of resilient wire which has a smooth bend intermediate to afirst portion110 and asecond portion114 of the retractor. Theretractor112 is described as having two portions for ease of description, although theretractor112 may be formed as an integrated structure. However,retractor112 may also be manufactured from twoseparate portions110,114 that are coupled together. Thefirst portion110 of theretractor112 is positioned within thecannula100 with theaxis111 of thefirst portion110 approximately parallel to theaxis101 of thecannula100. Thesecond portion114 is positioned to bend away from thecentral axis101 of the cannula. Theangle117 of displacement between theaxis115 of the second portion and thecentral axis101 ofcannula100 may be any angle from zero to 180 degrees. Thesecond portion114 includes adissection cradle116 at the distal end of thesecond portion114. Theretractor112 may be formed of bioinert material such as stainless steel, or a polymer such as nylon or polyetherimide, or other appropriately strong and resilient plastic. In one embodiment, theretractor112 includes a coating for lubrication, insulation, and low visual glare using, for example, parylene or nylon 11.

FIG. 2billustrates theretractor112 formed with two legs. Thelegs141,142 of theretractor112 at the distal end form thedissection cradle116 in a loop or “U” shape, as shown inFIG. 2a. Thetop portion144 of the U-shaped bend is preferably flattened to provide additional surface area for atraumatically supporting avein118 or vessel of interest. Theside arches128 of thedissection cradle116 are used for skeletonizing or dissecting the vein from the surrounding tissues, as well as acting as walls to keep the vessel captured within the arch. The several embodiments ofdissection cradle116 are described in more detail below.

FIG. 3aillustrates a perspective view of thecannula100 in accordance with the present invention with the retractor fully extended, holding asapphenous vein118, and also illustrates an externalsurgical tool120 disposed adjacent thecannula100 for performing a surgical operation, for example, severing a tributary or side branch of thevein118. The vein is positioned within theside arches128 of thecradle116. Thedissection cradle116 may be used to cradle a vein, vessel, tissue or organ of interest, andsurgical tool120 may be any surgical tool suitable for performing a surgical procedure near thedissection cradle116.

FIG. 3billustrates a perspective view ofcannula100 in an embodiment in which thesurgical tool120 is positioned within thecannula100, and anendoscope126 is present. In this embodiment,cradle116 preferably overlays theendoscope126 with sufficient clearance to facilitate relative movements thereof. However, the endoscope may also be located adjacent thesurgical tool120. In one embodiment,endoscope126 is positioned withcannula100 to allow a clear field of view upon extension of theretractor112.Surgical tool120 is illustrated as cauterizing scissors, used to sever a tributary or side branch of asapphenous vein118. In this embodiment,surgical tool120 is maximally displaced from thecradle116 at thecannula end122. More specifically, as shown inFIG. 3c, the “U”-shapedloop129 of thecradle116 is closest to thesurgical tool120. This ensures that avein118 or other tissue of interest is retracted away from thesurgical tool120 to facilitate manipulating thesurgical tool120 relative to the side branch or other tissue.

FIG. 4ais a cut-away top view ofcannula100. Theretractor112 is slidably positioned withinminor lumens113 along the length of thecannula100 within close tolerances in order to position theretractor112 stably within thecannula100. For example, in oneembodiment retractor legs141,142 are approximately 0.045 inches in diameter and thelumens113 encasing thelegs141,142 are approximately 0.080 inches in diameter, as friction between the legs of theretractor112 and thelumens113 holds the retractor stably within the cannula. This configuration restricts rotational movement of the retractor to provide more stable retraction as compared with conventional retractors. Thelegs141,142 of theretractor112 are formed of flexible, resilient material and are retained within thelumen113 in substantially straight or flat orientation, but may return to a material bend or curve, as illustrated inFIG. 5a, as theretractor112 is extended from the distal end of thecannula100.

Theleg141 of theretractor112 passes through a sliding gas orfluid seal130 at the proximal end of thelumen113. Theleg141 of theretractor112 passes out of thecannula100 and intohandle104 for attachment to aslider button106 for facilitating translational movement of theretractor112 from the proximal or handle end of thecannula100. However, other types of control devices such as knobs, grips, finger pads, and the like may be linked in conventional ways to theretractor112 in order to manually control the translational movement ofretractor112. In one configuration, the proximal end ofleg141 is bent relative to the axis of the cannula, and thebutton106 is attached to the bent position of theleg141 to facilitate moving thebutton106 and theretractor112 translationally under manual control. Thebutton106 preferably includes lateral grooves to prevent finger or thumb slippage during sliding manipulation of theretractor112.

Thus, in the operation of a preferred embodiment, a user actuates theslider button106 to extendretractor112 out of thelumen113 at the distal end of thecannula100. In one embodiment, theresilient retractor112 is formed in a smooth bend, as shown inFIG. 2a, and gradually deflects away from thecentral axis101 of thecannula100 as the retractor is extended. Upon encountering the target vessel or tissue of interest, the vessel is restrained in thecradle116, and a lateral resilient force is exerted on the target vessel in a direction away from the cannula. The vessel is thus pushed away from the axis of thecannula100, isolating it from surrounding tissue or adjacent vessels such as tributaries or side branches. As a tributary is thus isolated, asurgical tool120 such as cauterizing scissors may be safely employed to operate on the tributary without harming thesapphenous vein118. When retracted into thecannula100, theretractor112 is again resiliently straightened or flattened.

In an alternate embodiment as illustrated inFIGS. 5aand5b, a slidingtube132 is added to provide operational versatility tocannula100. In a first position, the slidingtube132 is retracted and theretractor112 protrudes from the distal end at an angle with respect to thecentral axis101 of thecannula100. In a second position, the slidingtube132 is extended out, temporarily straightening theretractor112. As illustrated inFIG. 5a, a slidingtube132, in a first position encases theretractor112 up to the point at which theretractor112 curves away from thecentral axis101 of the cannula thus allowing theretractor112 to displace and isolate a target vessel. The proximal end of the slidingtube132 is linked tobutton107 for translationally movingretractor112 as well as actuating the slidingtube132. In one embodiment, as illustrated inFIG. 5a, the slidingtube132 is in a first position with thebutton107 in an upright position. Aspring134 is coupled between asupport structure135 and theproximal end137 of the slidingtube132. In the first position of slidingtube132, thespring134 is extended fully and exerts little or no force on the slidingtube132. Of course, slidingtube132 may be manually manipulated without linkage to abutton107.

To extend the slidingtube100,button107 is pushed down. As illustrated inFIG. 5b, thebutton107 has acam surface136 which pushes on theproximal end137 of the slidingtube132 as thebutton107 is pressed. The slidingtube132 is pushed forward, overcoming the resilient force ofspring134, to encase theretractor112 anddecrease angle117 between the distal end of theretractor112 and thecentral axis101 of thecannula100. Upon releasing thebutton107, the spring force urges theproximal end137 of the slidingtube132 back toward the first position againstbutton107. The slidingtube132 is formed of material having sufficient strength to force theretractor112 to straighten out theangle117, and theretractor112 is formed of resilient material having a sufficient flexibility to straighten out theangle117 in response to atube132 being slid over theretractor112, but having sufficient rigidity to cradle and dissect a target vessel. Resiliency of theretractor112 ensures return to the downwardly-curved shape after being released fromtube132. Thus, in accordance with this embodiment, a user may employ the curved retractor for certain applications and employ the straightened form for other applications. A manual actuator may be configured in other ways thanbutton107 to extend the slidingtube132 in response, for example, to being pulled up instead of pushed down.

Another embodiment employs aretractor112 which has a naturally straight shape. As illustrated inFIGS. 6aand6b, anangling device140 is disposed between the distal end of theretractor112 and the proximal end of the cannula. Theangling device140 may be positioned within thesame lumens113 as theretractor112 and preferably may comprise two wires coupled to points below thecradle116 of theretractor112 substantially in parallel positions on each of thelegs141,142.

Upon extending theretractor112 usingbutton106, theangling device140 is extended with theretractor112. Theangling device140 is coupled to ahandle145 at the proximal end of thecannula100 to facilitate establishing an angle in theretractor112 by pulling with a backward force on theangling device140. As illustrated inFIG. 6b, after theretractor112 is extended, theangling device140 is actuated and a bend is created in theretractor112 as the backward force exerted on the distal end of the retractor is exerted against the relatively fixed position of theretractor legs141,142 disposed within thelumens113. As shown inFIG. 6c, theangling device140 may also be located in aseparate lumen202 from theretractor112 with part of theangling device140 positioned outside of thecannula100 when theretractor112 is in the retracted position.

FIG. 7aillustrates another embodiment ofcannula100 in which theretractor112 is pre-formed with oneleg141 of theretractor112 bent at an angle at its proximal end skewed to the axis of the distal end of theother leg142. The bent portion of theleg141 may be linked to a sliding knob147 for convenient manual manipulation of this embodiment of the invention. Upon sliding the knob147, theleg142 coupled to knob147 is twisted rotationally. The twolegs141,142 ofretractor112 are coupled together viacradle116. The axis of the second portion of theretractor112 in the first position is at afirst angle117 to the axis of thecannula100, as shown inFIG. 7b. As knob147 is moved,leg141 is rotated and crosses underleg142, as shown inFIG. 7c. This causescradle116 to flip 180 degrees and bends theretractor112 at asecond angle119, as shown inFIG. 7d. Thus, if a vessel is disposed on one side ofcradle116 orcannula100 while theretractor112 is in the first position, then upon rotating the knob147, the vessel is transported to the other side of thecannula100. This allows the user to isolate the vessel by simply actuating knob147.

FIG. 8aillustrates a cut-away side view ofbutton106 on thehandle104 ofcannula100, with anendoscope126 positioned withincannula100. As mentioned above,button106 is coupled to oneleg141 of the proximal end ofretractor112. Sliding thebutton106 ingroove146 translationally moves theretractor112.Groove146 is preferably minimally wider than the shaft ofbutton106 to minimize excessive horizontal movement ofbutton106 while still allowing smooth translational movement ofbutton106. As illustrated inFIG. 8b, thebutton106 may include locking or ratchetingteeth152 to give tactile feedback of its location, and to positively retain the button and the associatedleg141 in an extended or retracted position.Several mating teeth148 are located underneathgroove146, and aspring member150 is attached tobutton106 to exert pressure against the base ofgroove146, to engagemating teeth148,152. When a force is applied on the top ofbutton106, the interlocking sets of teeth are disengaged andbutton106 can move freely. Upon achieving the desired extension or retraction of theleg141,button106 is released and is retained place by the engagedteeth148,152.

FIG. 9aillustrates a top view ofcradle116 in an embodiment in which thecradle116 is formed by twolegs141,142 ofretractor112. The distal end of the legs form “U”-shaped side guides. The top144 of the distal portion of the “U” is preferably flattened. This provides atraumatic support for the target vessel retained withincradle116. Additionally, by minimizing the thickness ofdistal portion144, contact with other devices in close proximity withretractor112 is minimized.

Thecradle116 may have other effective shapes, for example, as illustrated inFIG. 9bin which a “C” ring element is attached to legs of thecradle116. The “C” ring may have asmall hole200 in one side with an axis approximately parallel to the axis of theretractor112. Thishole200 is used to hold suture or other ligating materials, and may also be used as a knot pusher. As shown inFIGS. 10aand10b, in an alternate embodiment of the embodiment ofFIG. 9b, theretractor112 is formed and flattened and a “C”-shaped ring is coupled to theretractor112 by, for example, gluing or molding the “C” ring to the distal end of theretractor112, as shown inFIG. 10cand10d.

Referring back toFIGS. 9c,9d, and9e, the side guides of the cradle may include aloop129 in a “V” shape, an arced “U” shape, or a semi-circular shape. In one embodiment, as illustrated inFIG. 9f, theretractor112 has only oneleg141, and thecradle116 is formed by theleg141. Astopper160 is coupled to the end of theleg141 to serve as a guide to retain the target vessel, and add a blunt surface to the end of the wire, for example, for pushing and probing tissue.FIG. 9gillustrates aretractor112 having aspur204 formed in one or bothlegs141,142 for allowing theretractor112 to be used for dissection. Sinusoidal, half-sinusoidal, and other geometric configurations may be used equally effectively as the shape ofloop129 in accordance with the present invention.

FIG. 11aillustrates atip1100 for use with amulti-lumen cannula100 housing anendoscope126. The taperedtip1100 may be removed from, and reattached to the distal end of acannula100, as desired. Upon attachment, thetip1100 seals the distal end of acannula100 in a fluid-tight manner. Thetip1100 is configured to provide dissection of the tissue surrounding the vessel of interest, and has a distal radius of approximately 0.045″ to reduce the hazard of penetrating the vessel of interest. The inner surface of thetip1100 tapers to a sharp interior point and a slightly rounded exterior point and thetip1100 has a uniform wall thickness. Thetip1100 preferably has taper angles of approximately 15° which provides a maximal, undistorted, visual field through anendoscope126. Thetip1100 tapers outward to a maximal diameter of about 12¾ mm at its shoulder to cover thecannula100 body which also has a diameter of about 12¾ mm. All of these features allow thetip1100 to effectively dissect tissue. Thetip1100 ofFIG. 11ahas a central axis1150 aligned with thecentral axis1108 of thecannula100. The visual field provided by theendoscope126, although satisfactory for surgical procedures, is not complete because theendoscope126 is in a lumen that is offset from thecentral axis1108 of thecannula100. Theendoscope126 is offset because of the space required inside thecannula100 for housing retractors and other instruments in adjacent lumens.FIG. 11billustrates thistip1100 detached from thecannula100.

FIG. 12aillustrates an offsettip1200 for acannula100 in accordance with the present invention. The offsettip1200 is a transparent, tapered tip as described above for use in endoscopic dissection of a vessel. However, in this embodiment theaxis1250 of thetip1200 is skewed relative to thecentral axis1108 of thecannula100. Theaxis1250 of thetip1200 is skewed approximately 8°, an angle that is chosen to align theapex1232 of thetip1200 with acentral axis1112 of theendoscope126, as shown in more detail inFIG. 12b.

FIG. 12billustrates the offsettip1200 housed incannula100 in more detail. Thecannula100 houses a 5mm endoscope126 having acentral axis1112 eccentric to thecentral axis1108 of thecannula100. In order to bring the distal end orapex1232 of the axis of the taperedtip1200 into the center of the visual field along thecentral axis1112 of theendoscope126, the taperedtip1200 is tilted or inclined by approximately 8° toward the lumen housing theendoscope126. This allows theapex1232 of thetip1200 to approximately intersect with thecentral axis1112 of theendoscope126. As illustrated inFIG. 12b, thetip1200 is inclined toward thecentral axis1112 of theendo scope126 without altering the taper angles1236 and1240 of the side walls. This is accomplished by forming atransition1228 between the proximal orcylindrical portion1204 of thetip1200 and the distal or conical portion of thecannula body1208 of thetip1200 substantially along aplane1230 that is skewed from normal to thecentral axis1108 of thecannula100. Thedistal portion1208 of thetip1200 retains its conical shape and equal taper angles1228,1236 between the side walls and the transition plane. The slight extension of the cannula body at the transition plane provides sufficient incline to allow theapex1232 of thetip1200 to intersect thecentral axis1112 of theendoscope126. Thetip1200 may be formed of separate conical and cylindrical parts that are attached together, or thetip1200 may be formed as an integrated structure in the shape thus described.

Alternatively, as shown inFIG. 12c, thetip1200 is inclined at a lesser angle, for example, 5 degrees, toward theaxis1112 of theendoscope126, positioning theaxis1250 of thedistal end1232 of thetip1200 intermediate between thecentral axis1108 of thecannula100 and theaxis1112 of theendoscope126. Positioning theaxis1250 of thetip1200 to this intermediate point allows the retention of steep conical angles in thetip1200 which allow for easier advancement of thecannula100 while using a minimal amount of force. The intermediate positioning also provides a more complete visual field as seen throughendoscope126.

An alternate embodiment of an offsettip1200 is shown inFIG. 13 in which the taper angles1320,1324 of the side walls are selected to form theapex1328 of thetip1200 aligned with thecentral axis1112 of theendoscope126. As illustrated, thelower region1316 of thecylindrical part1304 extends beyond theupper region1312 of the cylindrical part at a plane of transition between cylindrical and tapered regions of the tip. However, in this embodiment, the taper angles1320,1324 are not equal and the thirty degree angled conical configuration of thetapered part1308 is not maintained. Rather, thelower taper angle1324 is increased to an obtuse angle and theupper taper angle1320 is a reduced acute angle relative to the plane of transition between the cylindrical and tapered portions of the tip. In this configuration of theconical portion1308, theapex1328 of thetip1200 aligns with thecentral axis1112 of theendoscope126. Thus, in accordance with either embodiment, atip1200 is provided which allows a maximal visual field to be viewed by the surgeon via theendoscope126 that is eccentric thecentral axis1108 of thecannula100, but that is aligned with or near to theapex1232 of thetip1200.

FIG. 14aillustrates a perspective side view of the offsettip1200 and mountingrod1404. Thetip1200 is attached to thecannula100 via thelong rod1404 which extends through an eccentric lumen of thecannula100, as shown inFIG. 14b, and the apex of thetip1200 is tilted away from therod1404 and towards the endoscopic lumen (not shown). Theelongated rod1404 may be attached to thetip1200, or may be constructed as an integral part of thetip1200. Theelongated rod1404 preferably is secured inhousing1424, shown inFIG. 14c, viathreads1408 on the proximal end ofrod1404 and mating threads within nut orknob1416. Therod1404 andhousing1424 abut against the proximal end of thecannula handle1412, as illustrated in the perspective side view of the assembled device shown inFIG. 14d. Referring back toFIGS. 14a-c, thehousing1424 includes aslot1420 configured to slip over thelight cable outlet1428 on theendoscope126 as assembled within thecannula100. Thehousing1424 preferably contains arotating nut1416 which accepts the threadedproximal end1408 of therod1404. When tightened onto therod1404, as shown inFIG. 14d, thehousing1424 prevents thecannula100 from rotating about theendoscope126 by holding theendoscope126 fixed with respect to thehandle1412. This allows the operator to maintain the correct orientation of theendoscope126 on the vessel. If theendoscope126 is allowed to rotate freely, the image may turn sideways or upside down without the operator realizing it, and injury may occur to the vessel if thecannula100 is advanced in the wrong direction.

In one embodiment, as shown inFIGS. 14eand14f, theelongated rod1404 slips into thehousing1424 via agroove1450 near its proximal end, and passes through themain hole1454 in thehousing1424. Thegroove1450 allows for thehousing1424 to cover the proximal end of the mountingrod1404 without completely clearing the most proximal tip of the mountingrod1404. This allows more room for attaching thehousing1424 which lies between theelongated rod1404 and additional optical components. Therod1404 may contain an elastic section, or therod1404 may be somewhat elastic along its entire length to facilitate stretching therod1404 and pulling it into position in theslot1454 on thehousing1424, while locking thetip1200 in place. The elastic force also facilitates sealing thetip1200 against the distal face of the cannula body.

FIGS. 15aand15billustrates an alternate embodiment of offsettip1200 andcannula100. In this embodiment, offsettip1200 is formed with anelongated case1500 which slides over thecannula body100 and locks to the proximal end ofcannula100. In this embodiment, proximal end ofcannula100 is threaded and allows a threaded proximal section ofelongated case1500 to mate securely to thecannula100.

In a surgical procedure using the tissue-dissecting cannula of the present invention, the surgeon first incises1600 the skin overlying a vessel of interest to expose the vessel as an initial step of the procedure illustrated in the flow chart ofFIG. 16. A scissor tool is inserted1602 into the incision to create a path to the vessel by dissecting the overlying tissue. Next, thetip1200 of thecannula100 is inserted1604 into the incision to bluntly dissect tissue to form an initial tunnel along the vessel from the incision. The incision is then sealed1608 using a blunt tip trocar and a tunnel is insufflated1612. The cannula is advanced1616 along the vessel to dissect tissue adjacent the vessel under endoscopic visualization through the transparent tip. The offsettip1200 with the apex thereof in alignment with theendoscope126 provides a full visual field for the surgeon as thecannula100 is advanced. The conical end of thetip1200 dissects the tissue as thecannula100 is advanced along the vessel. The surgeon dissects both on the anterior and posterior sides of the vessel to create a full 360 degree tunnel around the vessel. Once a selected surgical site is reached, thecannula100 is removed1620 from the incision seal and thetip1200 is removed1624 from thecannula100. In one embodiment, as described above, thetip1200 is removed by unscrewing the threadedportion1408 of therod1404 from therotating nut1416. Thetip housing1424 itself is also removed in this embodiment. Insufflation is maintained and thecannula100 withouttip1200 is inserted1628 into the seal into the tunnel adjacent the vessel. Transecting devices are then inserted1630 into thecannula100. Withouttip1200 disposed over the distal end, thecannula100 can now be used for transecting1632 side branches and the ends of the vessel of interest using endoscopic instruments that are selectively installed and removed within instrument lumens in thecannula body100. After these procedures are completed, the vessel may be removed1636.

FIG. 17aillustrates another embodiment of an offsettip dilator1700. In this embodiment of the present invention, thetip1700 also includes wing-like protrusions for enlarging or dilating a peri-vascular cavity in the course of separating a vessel from adjacent connective tissue. For example, after tissue dissection with an offsettip1200 to form a tunnel or working cavity adjacent a target vessel by dissecting along the anterior and posterior sides of the vessel, thecannula100 is removed from the distal end of the body, the offsettip1200 is detached, and asecond tip1700 is attached to the distal end of thecannula body100. In one embodiment, thesecond tip1700 includes a transparent tapered tip with planar wing-like protrusions or extensions disposed proximal to thedistal end1720 of thetip1700. The wing-like protrusions1702,1704 each include a swept back leading edge. As shown inFIG. 17b, thetip1200 is tilted away from the mountingrod1404 to align with the central axis of an endoscopic lumen (not shown). The wing-like protrusions1702,1704 may also include curved distal and proximal edges, for example, in a parabolic configuration as shown inFIG. 17c, providing a smoother withdrawal of thecannula100 from the insufflated tunnel. Thetip1700 attaches to thecannula body100 in the same manner as previously described with reference to the offsettip1200, with anelongated rod1404 extending through a lumen of thecannula100 and locking at the proximal end of thehandle1412. Thecannula100 may thus be advanced through tissue under full-field endoscopic visualization through the taperedtip1720 with the wing-like protrusions1702,1704 extending substantially diametrically to facilitate tunnel dilation.

The wing-like protrusions1702,1704 of thetip1700 are arranged in substantially planar geometry in contrast to the solid bulbous, oval element described above. The planar configuration of the wing-like protrusions1702,1704 substantially reduce the frontal profile of the dilator required to penetrate tissue, and thus reduces the resistive force encountered during advancement of thecannula100 through tissue. Although the tissue-dilating force is exerted on tissue surrounding the cavity in a bilateral, substantially planar orientation by the outer edges of the wing-like protrusions1702,1704 that dissect tissue forming the cavity walls, the dilated cavity may retain a round cross-section for example, within an insufflated cavity, in the same manner as if tissue dilation was performed using a solid oval dilator that applies dilating force circumferentially.

FIG. 18 illustrates a method of dilating tissue in accordance with one method embodiment of the present invention. The skin is incised1800 overlying the vessel of interest, and the scissor tool is inserted into the incision to create a path to the vessel by dissecting the overlying tissue. The incision is then bluntly dissected1804 using the offsettip1200 to expose the vessel surface. The incision is sealed1808 and a tunnel is insufflated1812. Thecannula100 is advanced1816 along the vessel under endoscopic visualization through thetransparent tip1200. After sufficient length of tunnel is formed adjacent the vessel, thecannula100 is removed1820 and the incision seal is removed or slid backwards to the proximal end of thecannula100. The offsettip1200 is then replaced1824 with thedilating tip1700. The seal is reinserted and the incision is sealed1826. Thecannula100 is advanced1828 and the cavity is further dilated responsive to the advancement of the planar wing-like protrusions1702,1704 through tissue forming the tunnel walls. Thecannula100 is removed1832 a second time, and the incision seal is again removed or slid backwards to the proximal end of thecannula100. The dilating tip is removed1836 and the incision is sealed1837. Transection devices are loaded1838 through instrument lumens within thecannula body100 into thecannula100 and thecannula100 is then inserted1839 back into the incision. Without any tip covering the distal end of thecannula100, the vessel side branches and ends are transected1840 using endoscopic instruments, and the vessel is then removed1844 from the dilated tunnel.

Claims (14)

1. A surgical apparatus comprising:

an elongated cannula having a lumen extending therein between proximal and distal ends;

a retractor disposed to slide within the lumen to extend a distal end thereof beyond the distal end of the cannula;

an angling device connected to the retractor near the distal end of the retractor and extending within the cannula toward the proximal end thereof for selectively deflecting the distal end of the retractor away from a central axis of the cannula in response to manual manipulation of the angling device from near the proximal end of the cannula;

wherein the distal end of the retractor is configured to move, upon extension, an object away from the central axis of the cannula.

2. The surgical apparatus ofclaim 1, wherein a movement of at least a part of the retractor relative to the cannula is not parallel to the central axis.

3. The surgical apparatus ofclaim 1, wherein when the distal end of the retractor is extended beyond the distal end of the cannula, the elongated cannula provides access for a surgical tool to cooperate with the retractor to perform a surgical operation at a surgical site.

4. The surgical apparatus ofclaim 3, further comprising the surgical tool, the surgical tool configured to perform the surgical procedure at a location distal to the distal end of the cannula when the distal end of the retractor is extended beyond the distal end of the cannula.

5. The surgical apparatus according toclaim 1 in which the angling device includes a tension member extending within the cannula from attachment to the retractor beyond the distal end of the cannula, to a handle disposed near the proximal end of the cannula for selectively exerting tension on the retractor to deflect a portion of the retractor extended beyond the distal end of the cannula in response to manual pull applied to the handle relative to the cannula.

6. The surgical apparatus according toclaim 5, further comprising an auxiliary lumen extending within the cannula between distal and proximal ends thereof, wherein the tension member extends through the auxiliary lumen.

7. The surgical apparatus according toclaim 5, wherein the distal portion of the retractor is resiliently flexible for deflection in response to pull exerted thereon by the tension member.

8. The surgical apparatus according toclaim 5, wherein the retractor is disposed to engage a vessel structure for selectively displacing the vessel structure in response to tensile force exerted on the retractor through the tension member.

9. A surgical apparatus comprising:

an elongated cannula having a proximal end, a distal end, and a lumen extending between the proximal and distal ends;

a visualization tool located near the distal end of the elongated cannula;

a retractor having a distal end, the retractor disposed to slide within the lumen of the elongated cannula to extend the distal end of the retractor beyond the distal end of the cannula; and

an angling device connected near the distal end of the retractor and extending within the cannula toward the proximal end of the cannula, the angling device configured for selectively deflecting the distal end of the retractor away from a central axis of the cannula in response to manual manipulation of the angling device from near the proximal end of the cannula;

wherein when the retractor is not extended, the distal end of the retractor is adjacent to the visualization tool and at least partially encompasses the visualization tool.

10. The surgical apparatus ofclaim 9, wherein the distal end of the retractor has a first concave region that at least partially encompasses the visualization tool when the retractor is not extended.

11. The surgical apparatus ofclaim 10, wherein the retractor has a second concave region on an opposite side of distal end of the retractor from the first concave region.

12. The surgical apparatus ofclaim 9, wherein the visualization tool is an endoscope.

13. The surgical apparatus ofclaim 9, wherein the retractor allows a clear field of view of a surgical site by the visualization tool beyond the cannula upon extension of the retractor beyond the distal end of the cannula.

14. The surgical apparatus ofclaim 9, wherein the retractor, when extended, is configured to be used with a different surgical tool during a surgical procedure.

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